What Can Data Tell Us About the Quality and Relevance of Current Pediatric Residency Education?

Abstract

The Residency Review and Redesign (R3P) Project relied on both qualitative and quantitative data in developing its recommendations regarding residency education. This article reviews quantitative data in the published literature of import to the R3P Project as well as findings by Freed and colleagues published in this supplement to Pediatrics. Primary questions of interest to the R3P Project included: What factors drive decision-making regarding residency selection? Do current training programs have the flexibility to meet the needs of residents, no matter what their career choice with pediatrics? What areas need greater focus within residency training? Should the length of training remain at 36 months? Based on the available data, the R3P Project concluded that more diversity needs to be fostered with training programs. By promoting innovative and diverse approaches to improving pediatric residency education, members of the R3P Project hope to enhance learning, encourage multiple career paths within the broad field of pediatrics, and, ultimately, improve patient and family outcomes.

Three articles in this supplement to Pediatrics detail the proceedings from the Residency Review and Redesign in Pediatrics (R3P) Project colloquia.1–3 These dialogue-driven sessions provided crucial qualitative data relevant to the R3P Project. Using strategies commonly applied for strategic planning processes in the business, policy, and technology sectors, participants in the colloquia clarified their values regarding pediatric residency education, their concerns about factors affecting training, and their hopes for solutions. The interplay between participants allowed for greater understanding of different stakeholders’ perspectives regarding the developmental and historical processes influencing residency education and appreciation for the myriad social and political factors that contribute to our uncertainty regarding the state of pediatric residency education in the future.

Concurrently, participants of the R3P Project pursued a variety of sources to identify quantifiable data that would inform its recommendations. A review of current literature provided documentation of the changing demographics and disease/disorder patterns among children and adolescents in the United States and the implications for pediatric practice.4–7 There is a small but growing body of literature examining educational strategies and assessment measures in medical education.8–19 R3P Project participants also searched for data that have captured the voices of recently trained pediatric generalists and subspecialists and current subspecialty fellows and residents regarding residency choice and career choice, adequacy of pediatric training, and early experiences in practice or as junior faculty.

The picture that emerges from available data is that pediatricians who choose specialty training are more likely to be male,20 white,20 and interested in teaching,21 research,21,22 and technical procedures.21 Pediatric generalists parallel general internists and family physicians in highlighting long-term relationships with patients, broad content area, more time with their own families, and a primary focus on ambulatory care21,23,24 as important to their career choice. Residents going into primary care tend to prefer geographic areas with higher ratios of general pediatricians to children, higher median incomes, and urbanicity despite greater difficulty in finding positions in these locations than in areas with a comparatively low or moderate supply of physicians.25 Factors that have been mentioned as influences for favoring a decision to practice in underserved areas include training in an underserved location,26 minority race/ethnicity,26–28 female gender,28 sense of effectiveness,27 and the availability of loan-repayment programs or obligations.26,29

Studies published in the early 1990s that targeted graduates of pediatrics programs and directors of managed care companies decried a lack of preparation for primary care pediatrics practice.30–38 Most research conducted over the last decade has focused on specific topical areas rather than pediatrics residency training in its entirety. Generalists have reported discomfort managing depression,39,40 nutrition,41 in-office gynecology,41 and certain areas of developmental/behavioral pediatrics (ie, behavior problems, learning disabilities, sleep, anxiety).42 They do not feel adequately prepared to manage children with special health needs43 and desire better organizational policies regarding provider responsibilities, support for coordinated care, and additional education for children with chronic conditions such as attention-deficit/hyperactivity disorder.44 Practicing generalists and residents alike have reported insufficient preparation for office-based sports medicine.45,46 Both groups have reported a lack of essential knowledge of pediatric genetics, as well as how to communicate genetic information to families.47 Practical aspects of ambulatory care including patient scheduling, telephone management, and cost-effectiveness are areas of relative weakness.30,41 Changes in residency training over the last decade seem to have improved residents’ self-reported preparation for assessing community needs,48,49 participating in child advocacy efforts,49,50 and pursuing subspecialty training.49

The articles by Freed and colleagues in this supplement add to this nascent literature. The Freed et al survey of 7882 pediatrics residents as part of the 2007 American Board of Pediatrics in-training examination51 sheds light on the pediatrics residency experience. In 3 other articles they examine the perspectives of pediatrics generalists52 and subspecialists53 within the first 2 to 5 years after certification, as well as current pediatrics subspecialty fellows54 regarding their residency experiences and career choices. The tables display the results of additional analyses generated for this commentary: Table 1 compares the answers of generalists and subspecialists to questions about the factors considered in selecting a particular residency program and, generally, how more discretionary, flexible time in residency might be used; Table 2 compares preferences for more learning opportunities in specific content areas; and Table 3 examines the opinions of subspecialists and current fellows regarding the length of time required for residency and fellowship training.

Issues in Training: Comparison Between Subspecialist and Subspecialty Fellow Respondents in the Freed et al53,54 Survey

A primary question asked during the R3P process was: What factors drove decision-making regarding residency program selection for current residents, fellows, and early-career generalists and subspecialists? The surveys demonstrated both similarities and differences. For example, Table 1 shows that although geographic location of the residency program was the most important factor for both generalists and specialists, the importance of lifestyle issues, subspecialty expertise/training opportunities, prestige, and patient population varied. Response differences associated with gender, medical school (US or Canadian versus international), size of residency program, and subspecialty are discussed in detail by Freed et al.52–54

A second question raised by R3P Project participants was: Are current training programs flexible enough to meet training needs both for residents going into general pediatrics and those choosing subspecialty fellowship training? A careful review of the current review committee guidelines for pediatrics reveals a high degree of flexibility, with 8 to 9 months of undifferentiated time across the 33-month (allowing for 3 months of vacation) training period.55 However, participants of the R3P colloquia queried whether current programs were taking advantage of this flexibility to meet trainees’ needs. Two thirds of resident respondents affirmed that they were offered enough flexibility to meet their needs for their future career path during their residency training.51 In contrast, only 9% of recently certified generalists reported that they would not have made any changes in their residency training experience. If additional flexibility had been available, most would have pursued additional outpatient subspecialty (59%) or outpatient general (41%) care.52 Most fellows reported some flexibility during training, mainly in their choice of subspecialty electives, but desired more outpatient subspecialty (43%) and inpatient (41%) experiences. Although the proportion endorsing different settings varied between generalists and subspecialists (see Table 1), both desired more exposure to outpatient subspecialty care. A related finding by the Freed et al surveys of current fellows and early-career specialists was the variation in rotations endorsed among different subspecialty types, indicating that a “one-size-fits-all” residency program design is not desirable, even among residents who choose a subspecialty career.53,54

R3P participants also grappled with the question: What areas need greater focus within residency training? Because of the commonality of questions across surveys regarding additional training areas desired in residency, differences between generalists 1 to 5 years out from certification and current subspecialty fellows can be examined (see Table 2). Topical areas endorsed by approximately half or more of generalists included billing and coding (81%), mental health (62%), oral health (52%), sports medicine (51%), developmental/behavioral pediatrics (48%), and ophthalmology (47%). For subspecialty fellows, the areas endorsed varied substantially, with only billing and coding (65%) nominated by half or more of the respondents. Areas endorsed by approximately one third of the fellows included ophthalmology (38%), genetics (32%), allergy/immunology (32%), rheumatology (31%), and mental health (29%). The lack of consistently endorsed areas across subspecialties may reflect differences between subspecialty fields regarding areas of need for additional training; for example, a critical care provider may see less reason for additional experiences in adolescent medicine than a nephrologist who is concerned with the effects of a chronic renal disorder on puberty or the impact of adolescent individuation on adherence to treatment.

Statistically significant differences exist for each area between generalists and fellows. Some topics, such as genetics, were not strongly endorsed by either group but may be important to stress in current training, given projected scientific advances in these areas and future clinical demand. Others, such as ophthalmology and mental health, were substantially endorsed by both groups. For both generalists and subspecialists, the practical aspects of providing care are not being taught within continuity clinic or other experiences, as demonstrated by the high proportions wanting more training in billing and coding. Barron and Cassel56 recently stressed the disconnect between the care models espoused for patients with chronic disorders and current billing practices, as well as the lack of exposure to efficient clinical provision and billing for services during training. This area, although not often considered part of a pediatrics residency curriculum, seems to be highly relevant to pediatricians who recently completed residency training.

R3P Project participants also asked: How much time should be spent in residency training teaching residents to care for complicated patients with relatively uncommon conditions not often seen in primary care? Should the focus of instruction shift to principles of comanagement with subspecialists rather than management strategies alone? These questions bring into focus the ongoing debate regarding the role of the subspecialty electives in residency training. It may be that for those residents considering a generalist career path, the timing, content area, and setting for different subspecialty electives need to substantially change to better reflect the types of problems and patients they will be managing in primary care. The high proportions of generalists who endorsed additional outpatient training in a wide variety of subspecialty areas parallel a proposal by Forrest et al57 to develop clinical competencies during pediatrics residency training for the 50 most commonly referred conditions. This may be challenging for sites without pediatrics subspecialists that may rely on internists or nonsubspecialists to teach curricular items (as documented, eg, with pediatric rheumatology).58 For pediatricians who intend to practice in rural or other areas without easy subspecialty access, comanagement using telemedicine technologies or additional exposure to and responsibility for complicated patients may be necessary. For all trainees, mechanisms for communicating efficiently and clearly regarding diagnosis and treatment demand attention during training, given the results of 2 recent studies on generalist-specialist communication57,59 and similar deficiencies that are likely to exist in specialist-specialist communication.

An additional question examined during the R3P Project was: Should the length of pediatrics residency training remain at 36 months or vary for individuals who define their career goals early in their training? This discussion usually arises within the context of residents who choose a subspecialty career and may want to fast-track into subspecialty training. Interestingly, approximately two thirds of subspecialist fellows had decided on fellowship training by their first postgraduate year (PGY-1); this proportion rose to 91% by PGY-2.54 Despite this early differentiation, approximately two thirds of current fellows and subspecialists endorsed maintenance of a 3-year residency program.53,54 In addition, one third of PGY-3 residents desired more career mentorship for their career decisions.51 This desire for mentorship may partially reflect residents who are not yet certain regarding their future career trajectories; it may also signal the need for counsel regarding the factors to be considered in identifying a practice site or fellowship training program. Taken together, these findings suggest that PGY-3 may be important developmentally for residents with respect to self-definition and consideration of the appropriate location and setting for their postresidency career. These findings deserve further exploration.

One unanticipated finding was related to the length of residency training in combination with subspecialty training. In the resident survey, one third of the residents reported that they would be more likely to choose a subspecialty if the sum of residency and subspecialty training were 5 years, as it is in internal medicine.51 Current subspecialty fellows and practicing subspecialists as a group tended to support a 3-year residency program (see Table 3); however, 52% of current subspecialty fellows endorsed a 2-year fellowship without research, compared with 42% of subspecialists 2 to 5 years after certification (P < .001). These findings raise several issues still in discussion within the pediatrics community. First, how do we best support high levels of interest in developing clinical expertise in subspecialty areas among generalists? Concurrently, what is driving the lack of enthusiasm for a third year of fellowship training focused on research despite recent changes in the requirements for subspecialty certification that allow more broadly defined research projects? Are we not teaching the applicability of research training to high-quality clinical care? What steps can be taken during medical school and residency training to enhance interest in research? How do academic medical centers support faculty in research endeavors during a time of increasing focus on clinical productivity?

The results from these 4 studies, other available published studies, and the insights of members of the pediatrics community led the R3P Project to prioritize variability in training approaches as a central tenet in pediatrics residency education innovation.1 Instead of trying to apply a one-size-fits-all approach to residency, R3P Project participants overwhelmingly concluded that residency training should be tailored to meet the diverse career needs of individuals who choose to care for disparate patients, in diverse settings, with a variety of health-related needs. Programs should capitalize on the flexibility under the current review committee guidelines as well as through the waiver process to creatively experiment in designing programs.55 Programs also should take a patient-based perspective, tailoring training to the diverse and emerging health care needs of the pediatric population, to prepare residents to address these needs in their future practice and/or research settings.

These findings also ultimately led to the R3P Project participants’ conclusion that the promise of improving the quality and relevance of pediatrics residency education springs from this very diversity in career goals and patient profiles. Instead of recommending general changes in the number of months in a particular setting or the required numbers of continuity clinics for all residency training programs, those participating in the R3P Project embraced encouraging diverse innovative approaches to improving education.3,60 In this endeavor, we can profit from the experiences of internal medicine and family medicine, because both fields are going through a similar methodology to achieve improvements in their residency training programs.61–65 It is our hope that creative approaches fostered under this process will enhance learning, improve patient and family outcomes, and lead to more efficient, effective pediatric care.

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